The document details various clinical and laboratory tests used to assess vestibular functions, including spontaneous nystagmus, Romberg's test, and caloric testing. It explains the distinctions between peripheral and central nystagmus as well as conditions that affect vestibular function. Additionally, it describes specific diagnostic maneuvers and tests for cerebellar and vestibular impairment.

1. Assessment of
Vestibular Functions
Venkatesh Karthikeyan
III MBBS
Velammal Medical College
Email: 4852012@gmail.com

2. Tests done
Clinical Tests
Laboratory test
Vestibular Function Test

3. Clinical tests
Spontaneous nystagmus
Fistula test
Romberg’s test
Gait
Past pointing and falling
Dix - Hallpike manoeuver (positional test)
Test of cerebellar dysfunction
Vestibular Function Test

4. Laboratory tests
Caloric test
Electronystagmography
Optokinetic test
Rotation test
Galvanic test
Posturography
Vestibular Function Test

5. Clinical tests
Spontaneous nystagmus
Fistula test
Romberg test
Gait
Post pointing and falling
Hallpike manoeuver (positional test)
Test of cerebellar dysfunction
Vestibular Function Test

6. Spontaneous Nystagmus
Nystagmus:
 Rhythmical
 Involuntary
 Oscillatory movement of eyes

7. Types of nystagmus
Horizontal nystagmus
Vertical nystagmus
Rotatory nystagmus

8. Horizontal nystagmus
Direction of fast component Direction of slow component
Direction of Nystagmus

9. Vertical Nystagmus

10. Rotatory Nystagmus

11. Eliciting Nystagmus
Patient is seated in front of examiner or lies supine on
the bed.
Finger at 30 cm from patient’s eye in central position.
Move the finger.
Avoid Gaze nystagmus.
SPONTANEOUS NYSTAGMUS ALWAYS INDICATES
AN ORGANIC LESION.

12. VESTIBULAR NYSTAGMUS
 Peripheral – due to lesion in labyrinth or CN VIII
 Central – due to lesion in vestibular nuclei or brainstem or
cerebellum

13. Peripheral Nystagmus
 Irritative lesions of the labyrinth (serous labyrinthitis) –
nystagmus to the side of lesion.
 Paretic lesions – nystagmus to healthy side (purulent labyrinthitis,
trauma to labyrinth and section of VIIIth nerve)
 Suppressed by optic fixation by looking at fixed point
 Enhanced in darkness or by using Frenzel glasses (+20 D)

15. Central Nystagmus
Cannot be suppressed by Optic fixation.
Types of Central Nystagmus:
 Torsional Nystagmus
 Vertical downbeat Nystagmus
 Vertical Upbeat Nystagmus
 Pendular Nystagmus

16. Type of Nystagmus Level of Lesion Conditions in which
it is seen
Torsional nystagmus Brainstem or
Vestibular nuclei
Syringomyelia
Vertical downbeat
nystagmus
Craniocervical region Arnold Chiari
malformation or
degenerative lesions
of cerebellum
Vertical upbeat
nystagmus
Junction of Pons and
medulla or pons and
midbrain
-
Pendular nystagmus - • Congenital or
Multiple Sclerosis
• Maybe
disconjugate

18. Clinical tests
Spontaneous nystagmus
Fistula test
Romberg test
Gait
Past pointing and falling
Hallpike manoeuver (positional test)
Test of cerebellar dysfunction
Vestibular Function Test

19. Fistula Test
Basis of the test : Inducing nystagmus by
producing pressure changes in external ear
which are then transmitted to labyrinth
True Negative – Normal

20. Fistula test - True Positive
 Erosion of horizontal semicircular canal as in cholesteatoma
 Surgically created window in horizontal canal (Fenestration)
 Abnormal opening in oval window (post stapedectomy fistula)
 Abnormal opening in round window (Rupture of round window)

21. Fistula Test – False Negative
Dead labyrinth
Cholesteatoma covering the site of fistula
and not allowing the pressure changes to
be transmitted to labyrinth.

22. Fistula test – False positive
Congenital syphilis – due to hypermobile stapes
footplate
Meniere’s disease – due to fibrous bands
connecting utricular macula to stapes footplate.
In both these conditions, movement of stapes
results in stimulation of Utricular macula.

24. Clinical tests
Spontaneous nystagmus
Fistula test
Romberg test
Gait
Past pointing and falling
Hallpike manoeuver (positional test)
Test of cerebellar dysfunction
Vestibular Function Test

25. Romberg Test
• Peripheral Vestibular Lesion – patients
sways to side of lesion.
• Central Vestibular Lesion – patient
shows instability.

26. Sharpened Romberg Test
Inability indicates Vestibular impairment

27. Clinical tests
Spontaneous nystagmus
Fistula test
Romberg test
Gait
Post pointing and falling
Hallpike manoeuver (positional test)
Test of cerebellar dysfunction
Vestibular Function Test

28. Gait
In case of uncompensated lesions of peripheral vestibular system, with eyes
closed, the patient deviates to affected side

29. Clinical tests
Spontaneous nystagmus
Fistula test
Romberg test
Gait
Past pointing and falling
Hallpike manoeuver (positional test)
Test of cerebellar dysfunction
Vestibular Function Test

31. Clinical tests
Spontaneous nystagmus
Fistula test
Romberg test
Gait
Past pointing and falling
Hallpike manoeuver (positional test)
Test of cerebellar dysfunction
Vestibular Function Test

32. Hallpike manoeuvre
Useful when patient complains of vertigo in certain
head positions
Helps differentiate a peripheral from a central
lesion

34. Positional Nystagmus elicited by
Hallpike maneuver
Peripheral lesion Central lesion
Latency 2-20 seconds No latency
Duration <1 minute >1 minute
Direction of
nystagmus
Direction fixed Direction changing
Fatigability Fatigable (disappears
on subsequent
repetitions)
Non fatigable
Accompanying
symptoms
Severe vertigo None or slight

35. Clinical tests
Spontaneous nystagmus
Fistula test
Romberg test
Gait
Post pointing and falling
Hallpike manoeuver (positional test)
Test of cerebellar dysfunction
Vestibular Function Test

36. Test for Cerebellar function
All cases of giddiness should be tested
for cerebellar diseases.
 Diseases of cerebellar hemisphere causes:
 Asynergia (abnormal finger nose test)
 Dysmetria (inability to control range of motion)
 Adiadochokinesia (inability to perform rapid
alternative movements)
 Rebound phenomenon (inability to control movements
of extremity when opposing forceful restraint is
suddenly released)

37. Midline diseases of cerebellum causes:
 Wide based gait
 Falling in any direction
 Inability to make sudden turns while walking
 Truncal ataxia

38. Laboratory tests
Caloric test
 Electronystagmography
 Optokinetic test
 Rotation test
 Galvanic test
 Posturography
Vestibular Function Test

39. Caloric Test
Basis : Induce nystagmus by thermal stimulation of
vestibular system.
Advantage : Each labyrinth can be tested
separately.
Helps proving labyrinthine origin of vertigo.

40. Caloric Tests
Modified Kobrak test
Fitzgerald-Hallpike test
Cold-air caloric test

41. Modified Kobrak test
Patient seated with head tilted 60 degrees
backwards (Horizontal canal  Vertical in
position)
Ear is irrigated with cold water for 60 seconds.
 5mL
 10mL
 20mL
 40mL

42. Normal – Nystagmus beating towards opposite ear
with 5mL of ice water
Hypoactive labyrinth – response with increased
quantities of water (5 to 40 mL)
Dead labyrinth – no response to 40 mL of water

43. Fitzgerald – Hallpike test

44. Irrigate the ears for 40 seconds alternately with water at 300 C
and at 440 C
Eyes are observed for appearance of nystagmus till its end
point
Chart the time taken from the start of irrigation to the end
point of nystagmus on a calorigram
If no nystagmus is elicited from any eye, test is repeated with
the water at 200 C for 4 minutes before labelling the labyrinth
dead.
Allow a gap of 5 minutes between two ears

45. • Cold water - Nystagmus to opposite side
• Warm water – Nystagmus to same side

46. Caloric test helps in assessing:
Canal paresis – response elicited from a
particular canal after stimulation is less than that
from opposite side
Directional preponderance – Duration of
nystagmus to left or right, irrespective of whether
it is elicited from the right or left labyrinth

47. Canal paresis
 It can be expressed as percentage of total response from
both ears.
Response from left ear = L30 + L44
L30 + L44 + R30 + R44
Response from right ear = R30 + R44
L30 + L44 + R30 + R44
X 100
X 100

48. Less or no response from particular side is
indicative of depressed function of ipsilateral
labyrinth or vestibular nerve or vestibular nuclei.
Depressed functions are seen with:
Meniere’s disease
Acoustic neuroma
Post labyrinthectomy
Vestibular nerve section

49. Directional preponderance
 Right beating nystagmus is caused by L30 and R44 (COWS)
 Left beating nystagmus is caused by L44 and R30
Right beating nystagmus = L30 + R44
L30 + L44 + R30 + R44
Left beating nystagmus = L44 and R30
L30 + L44 + R30 + R44
X 100
X 100

50.  If nystagmus is 25 – 30% or more on one side than the other
side, it is called directional preponderance to that side.
Directional preponderance occurs towards the
side of central lesion, away from side of
peripheral lesion.
Unilateral Meniere’s disease – Canal paresis on
one side and directional preponderance to
opposite side
Acoustic neuroma – Both to ipsilateral side

53. Laboratory tests
 Caloric test
Electronystagmography
 Optokinetic test
 Rotation test
 Galvanic test
 Posturography
Vestibular Function Test

54. Electro-nystagmo-graphy
 Depends on presence of corneo-retinal potentials which are
recorded by placing electrodes at suitable places around the
eye.
 Used for:
 Detecting nystagmus (even which is not seen by naked eye)
 Recording nystagmus (permits to keep a permanent record)

55. Laboratory tests
 Caloric test
 Electronystagmography
Optokinetic test
 Rotation test
 Galvanic test
 Posturography
Vestibular Function Test

56. Optokinetic test
 Used to diagnose central lesions (brainstem and cerebral
hemisphere lesions)
Normally, it produces nystagmus with slow component in the direction of
moving stripes and fast component in opposite direction
R  L
L  R

57. Laboratory tests
 Caloric test
 Electronystagmography
 Optokinetic test
Rotation test
 Galvanic test
 Posturography
Vestibular Function Test

59. Rotational test
 Patient seated with head tilted 300 forward
 Rotated 10 turns in 20 seconds
 Stop the chair abruptly and observe the nystagmus (Normal :
25-40 seconds)
 Performed in case of congenital abnormalities where ear
canal has failed to develop (unable to perform caloric test)
 Disadvantage : Labyrinths cannot be tested individually

60. Laboratory tests
 Caloric test
 Electronystagmography
 Optokinetic test
 Rotation test
Galvanic test
 Posturography
Vestibular Function Test

61. Galvanic test
Helps differentiating end organ lesion from
vestibular nerve lesion.
Feet together, eyes closed, arms out-stretched.
Current of 1 mA passed to one ear – normally,
patient sways towards side of anodal current.

63. Laboratory tests
 Caloric test
 Electronystagmography
 Optokinetic test
 Rotation test
 Galvanic test
Posturography
Vestibular Function Test

64. Helps in evaluating vestibular function by measuring postural stability

65. Firing Round

71. Thank you 
Adam Politzer – Father of modern Otology